Re-circumcision

It is widely recognized by pediatric urologists that male circumcision reduces the risk of urinary tract infections, penile cancer, and transmission of some sexually transmitted infections, including HIV.
Although the majority of circumcisions in infants occur without complication, a percentage of children require urology intervention.

Boston Children’s Hospital urologist Erin R. McNamara, MD, MPH, discusses the complications associated with circumcision, why a revision is necessary and when to see a pediatric urologist.

Why is a circumcision revision necessary?

When a child is circumcised, sometimes the skin from the penis attaches to the head of the penis and forms adhesions. This usually occurs because too much skin was left behind during the original circumcision (incomplete circumcision/redundant foreskin). The extra skin covers the head of the penis, and it can cause mild adhesions or completely cover the penis to the point where it no longer looks circumcised. It depends on how much extra skin is left behind. The redundant skin also can be uneven with more extra skin on one side versus the other side.

Often, a revision is done because the redundant skin may lead to irritation or infection. These infections may be due to the adhesions or if the adhesions are so dense (penile skin bridges) that they can actually cause discomfort or curvature of the penis with erections. These are the only health indications for doing a revision. Revisions are also done if there is so much skin that it doesn’t look circumcised or if the skin left behind is uneven. The child will not “grow into” the extra skin so we often make the recommendation for revision if there is a lot of extra skin and the adhesions keep coming back.

What are the common complications of a neonatal circumcision?

Fortunately there are no “common” complications of neonatal circumcision since it is such a safe procedure. Occasionally, a child can have bleeding that either stops with a pressure dressing. Very rarely, a suture needs to be placed to stop the bleeding.
Other things that can happen are injuries to the glans or the urethra if the clamp that is used for circumcision is not placed correctly.

Hypospadias: Rarely, a patient will have a hypospadias, which goes undetected until after the circumcision. This is unfortunate because urologists use the foreskin to fix the hypospadias.

Another rare complication is taking too much skin off during a circumcision, so the shaft of the penis is not covered with skin. This will sometimes need to be fixed in the operating room.

Incomplete circumcision: More commonly, too little skin is removed (also called an incomplete circumcision), and there is redundant foreskin. When this occurs, the child may have a build up of normal skin cells, or smegma, underneath the extra skin, which leads to irritation, infection or adhesions of the skin to the head of the penis.

When should the child be seen by a pediatric urologist?

If he has had any skin infections or the parents have concerns about the circumcision, the child should see a specialist. Some pediatric urologists can lyse the adhesions in the clinic with local numbing medicine. However, if extra skin is causing the problem, this will need to be addressed in the operating room under anesthesia. Consultation with a pediatric urologist is the only way to determine if a revision is necessary.

How do you perform a circumcision revision?

Once under anesthesia, we put local anesthetic near the penis to minimize post-procedure pain. At this point, we safely lyse or remove the penile adhesions. If the adhesions are dense, we cut them and remove the extra skin so there is no redundant skin left behind. We make sure there are no small vessels bleeding and place small stitches. Sometimes a dressing is placed with bacitracin and the child is woken up and goes to the recovery room. They go home that same day.

Is there anything else parents should know about circumcision revision?

Fortunately, this is a very minor procedure. Anesthesia is safe in this age group, and a revision circumcision does not take a long time. The adhesions will continue to come back unless the extra skin is removed. The extra skin that is removed will make the penis look like a circumcised penis. Once the circumcision has been revised, it is extremely rare for any further problems to occur.

Erin McNamara, MD, MPH, is a urologist at Boston Children’s Hospital and an instructor in surgery at Harvard Medical School.

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